The results of the validation process of the adapted SERVPERF scale present a valid instrument for measuring satisfaction and quality of service in patients who request a MA.
The sociodemographic characteristics of the participants are similar to those of the population in Catalonia that requests a MA, according to the 2018 statistics reported by the Department of Health [5]. The most relevant difference is that 42% of patients were locals in the reported statistics, while in our study 66.3% were. This is most likely explained by having included improficiency in Spanish as an exclusion criterion.
Prior to this study, the effectiveness of the MA process had already been demonstrated and supported by protocols [5], but no data had been collected on quality as perceived by patients. In 2019, the first article on a validated, person-centered abortion care scale was published in Kenya [24]. The lack of data on the quality of abortion care may be due to the highly stigmatized status of the procedure.
McLemore assessed the experience of the outpatient abortion process in the United States: 70% of patients reported having had a better experience than expected; the rest mentioned the need to improve pain management and waiting time [21]. These findings support the decision to include 5 items related to the MA process in our proposal.
In 2020, Sudhinaraset et al. [25] published a validation of a person-centered abortion scale, in both surgical and medical private care, in a restrictive legal context of abortion. The dimensions of respectful care and communication predominated. They found that these types of scales can be adapted for different sexual and reproductive health services. Our scale also assesses the organization, clinical aspects and impact of the process.
Baynes studied how women experience post-MA visits in Tanzania [26]. Although the women were satisfied with the privacy and proximity of care, they identified significant areas for improvement: office cleanliness, post-contraception counseling, and pain management. In our study, the quality of these aspects was assessed as good. The scale presents good metric characteristics since it does not show saturated floor or ceiling effects and there was a high response rate for all items. The non-response rates for items 22–24 might be due to their placement on the back page of the questionnaire [23].
In general, the scores were high for all items, except for 19–23, which were related to the MA process. This is consistent with other studies in which items related to pain management, bleeding, and anxiety during the process scored lower [20, 21].
In the factor analysis, 7 dimensions were obtained that explain a total variance of 65.9%, similar to that obtained by Gómez-Besteiro (69.3%) [18].
The items added to address the process were grouped into two specific dimensions, which was deemed coherent.
In general, item agreement was moderate to excellent, except for items 6, 8 and 11, for which it was moderate, likely due to a certain degree of subjectivity. Predisposition, time dedicated and sufficient information may be perceived differently depending on patients’ need for support.
Item 17, which asked about the information provided to prevent unwanted pregnancies in the future, showed low reliability. This was also observed in the Baynes study as an aspect to be improved [26]. One solution would be to provide this information at the end of the process along with free contraception.
The dimensions obtained are similar to those proposed in other SERVPERF validation processes for healthcare. Gómez-Besteiro obtained the same 5 dimensions but distinguished between medical and nursing staff [18]. In our study, the healthcare professionals dimension included gynecologists and midwives, since both are involved in the process. Torres obtained 7 dimensions, including safety [27], which has already been analyzed in our area [5].
As for the limitations of this study, the important ethical-moral connotation of MAs must be considered. Although it is currently legal, it is still an ethical conflict. This factor may have influenced the number of study dropouts.
After performing the MA, some women did not attend follow-up visits. However, the dropout rate was low (13.2%) and no differences were observed that would suggest the existence of any type of risk.
